Chapter 8
Chapter 8
Chapter 8
Chapter 8
Chapter 8
100
Caused for profit insurers to use experience rather than community ratings to establish premiums
What is not one of the major impacts of the establishments of Blue Cross for hospital care and blue shield for physician services
100
Disease management programs
What is cost-control initiatives undertaken by managed care organizations to improve communications with chronic disease patients in the hope of avoiding unnecessary costly care.
100
Enacted in 1983, the diagnosis related groups payment methodology shifted hospital reimbursement from the retrospective to prospective basis in order toro die financial incentives for hospitals to spend no more than needed toproduce optimal outcomes for hospitalized patients
What is the major purpose of DRGs
100
Prevention and health promotion Management of acute conditions Management of chronic conditions Family experience of care Availability of services
What are the five criteria for assessing the quality of Medicaid services
100
"Backlash" the result of consumer dissatisfaction with managed care plans in terms of perceived quality of care, constraints on receiving perceived necessary care, restrictions on referrals to specialists. Managed care organizations offered more "Point of Service plans to allow members greater freedom of choice in providers A federal commission waste stablished to review the need for managed care industry guidelines Several states enacted new requirements for independent dispute resolution when patients are denied payment for what is deemed necessary care A national patient bill of rights was introduced and remains pending before congress Some employers began allowing employees to make personal decisions about coverage rather than limiting choice only to selected plans
What is meant by "backlash" in reference to managed care. Provide at least three significant ways in which managed care organizations and or policy makers responded to this consumer phenomenon
200
Rapidly increasing Medicare expenditures accompanied by quality concerns captured the attention of health and government policy makers which resulted in the enactment of
What is Health Maintenance Organization Act of 1973
200
Health care providers and consumers protesting managed care's restrictive policies on provider choice, referrals to specialty care and other practices.
What is "Managed care backlash"
200
The Centers for Medicare $ Medicaid services developed a web based program to provide consumers with objective criteria that allow comparisons of hospitals use of evidence based practices and patient satisfaction ratings
What is "Hospital Compare"
200
Beginning in 2014 the ACA requires most Americans to carry health insurance coverage or be penalized with an annual tax
What is meant by individual mandate
200
Care is often delayed and conditions worsen Treatment may be more intensive therefore more costly Use of hospital emergency depts s higher in this group Preventive are is ignored Uninsured are four times more likely to require hospitalization that would have been avoidable wit earlier intervention Uncovered costs are absorbed by providers
Millions of Americans presently lack or have inadequate health insurance coverage. Discuss at least three dimensions ofthefinancial and personal impact of this phenomenon
300
By focusing on insured populations rather than individuals, managed care organizations can project health service use by.....
What is demographic factors such as age, gender, and other factors
300
The National Committee on Quality Assurance (NCQA)
What is the most influential managed care quality assurance organization that accredits many different aspects of managed care organizations on a voluntary basis
300
Create a competitive health insurance market by providing web based easily understandable comparative information to consumers on plan choices with standardized rules regarding health plan offers and pricing
What is the purpose of HIEs (health insurance exchanges)
300
Advanced medical technology Growth in the population of older adults Emphasis on specialty medicine Labor intensity Reimbursement system incentives
What are three major factors that have contributed t increased health care expenditures
400
Physicians agreeing to provide all medical care an individual requires for a specified time period for prepaid fee
What is capitation
400
A standardized method for managed care organizations to collect, calculate and report information about their performance to facilitate purchasers' and consumers comparisons of different insurance plans on a variety of parameters.
What is HEDIS (healthcare Effectiveness Data and Information Set)
400
Enacted in 1965 as a title XIX of the social Security Act as a joint federal state program supporting basic health services for low income individuals and to which federal and state support is shared based on a states per capita income
What is Medicaid
400
Fee for service payments for individual services provided during a beneficiaries illness resulting in fragmented care with minimal coordination across providers and settings that result in rewarding service quantity rather than quality
What does the "Bundled Payments for Care Improvement Initiative" address
500
An aim of managed care is to transfer some measure of financial risk to providers and to a lesser extent patients. This is accomplished by what means
What is requiring co-payments and deductibles. Co-payments require the beneficiaries pay a set fee each time they receive a covered service. A deductible requires beneficiaries to meet a predetermined, out of pocket expenditure level before the MCO assumes payment responsibility for the balance of charges.
500
The Medicare program enacted in 1965 as title XVII of the 1935 Social Security Act is characterized as the most sweeping social legislation ever enacted by the federal government
What is the second mandated US health insurance program after workers compensation and signaled the federal governments entry into the personal healthcare financing arena
500
Intent to enroll 10 million uninsured children in Medicaid whose family incomes were too high to qualify for Medicaid but too low to purchase private health insurance
What is CHIP (Medicaid Child Health Insurance Program
500
Changes from prior philosophies of providers individually based care perspectives to perspectives on achieving improved population health status Changes in medical and other professional schools educational curricula to include emphasis on population health Recognizing that medical technology cannot solve the overarching problems of providing care for increasing numbers of aged and chronically I'll Americans
What are some of the most challenging issues that will confront policy makers
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